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Child-Maltreatment-Research-L (CMRL) List Serve

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Welcome to the database of past Child-Maltreatment-Research-L (CMRL) list serve messages. The table below contains all past CMRL messages (text only, no attachments) from Nov. 20, 1996 - December 22, 2017 and is updated quarterly.

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Message ID: 7982
Date: 2009-01-05

Author:Sandra Azar

Subject:RE: Evidence-based and "Mix and Match" Programs

Mark and Ben,



I am hesitant to get into the dialogue of two such titans in the field, but

am struck as I always am about the missing elements in our treatment

discussions. Both of you make incredibly important points and I too believe

deeply in science guiding our planning of treatment. But this discussion

leaves out two important elements in child protection work -- that I believe

we often we as researchers ignore -- WHO is actually doing the work and the

CONTEXT in which it is done. Coupled with the risk of a child death, both

may explain the desire to add and add and add.



Who - Most parent home visitors and caseworkers are not trained to do the

kind of work we want them to do. Indeed, I have seen home visitors who are

bank tellers or human resource workers or ones who did housing work. None

with prior training more than a workshop here and there. So we can develop

whatever intervention we like --we are still expecting someone to carry it

out. In many contract agency settings, supervision is minimal and

backgrounds of staff do not match the requirements of our protocols.



Where - In urban settings when I have visited homes to conduct research

interviews or in the past to do home interventions, I often have gone to

neighborhoods where a shooting has taken place just a week ago (setting off

a sense of vigilance even though I am seasoned in going to such

neighborhoods). I might have to step over a drunken neighbor who is passed

out on the stoop or the half drunk one, who insists on having a conversation

with me before I can get past them to get into the home. I then enter homes

where at times I am treated to a shouting argument between a man and a woman

that at moment feels like it will erupt into a physical fight. Other men

enter the home during the visit and stare rather belligerently at me or join

in taking the boyfriend's or husband's side. The woman may have no food and

the child appears sick. She is crying. This is the context where the work

is being done. Cognitive science tells us that cognition is disrupted under

such conditions.



Put a frightened young worker and this context together and add high risk

for a child and the worker is overwhelmed and wants all the help she can get

and probably is shaking too much to carry out anything in any standardized

way. It FEELS like more is better -- because the situation has so many

elements. She may habituate to this over time and with good supervision grow

into a decent practitioner who can carry out focused approaches. More likely

if she is good, she will leave the work for a job in a setting where she can

feel safe and carry out her work more effectively.



Yes -- in a the context of a workshop and under ideal conditions with the

right coach, caseworkers can come up with a good treatment plan that is

focused and may be enough to produce results -- but that is with a coach

like one of you and the safety of sitting in a room with nothing to lose and

no threats hanging over them.



Treatment development work in child maltreatment is unlike other treatment

development areas where most interventions are carried out by professionals

who have much education and in the context of an office setting. I want the

field to develop science based protocols, but until we deal with staffing

issues and focus our attention on methods for coping for staff -- the "add

and add and add" approach will continue to feel safer for most.



Sandra



------------

Sandra T. Azar, Ph.D.

Professor

Psychology Department, Moore 541

Pennsylvania State University

University Park, PA l6801

814-863-6019 (office)

sta10@psu.edu



-----Original Message-----

From: bounce-3424753-6833833@list.cornell.edu

[mailto:bounce-3424753-6833833@list.cornell.edu] On Behalf Of Saunders PhD,

Benjamin E

Sent: Friday, December 26, 2008 11:44 PM

To: Child Maltreatment Researchers

Subject: RE: Evidence-based and "Mix and Match" Programs



Mark,

Thank you for the excellent summary of several very important issues. Two

points are particularly critical for future research. IMHO, the current

excitement in some quarters over "components" approaches to treatment vs.

manualized "protocols" is, from a research perspective, a red herring. As

you note, both must have some sort of decision rules about what to do next

at certain points in treatment. If not, they just become virtually random

in nature. So, the results of those decisions will need to be tested

empirically whether it means following a "protocol" or decision rules about

using components. Frankly, when one scratches the surface, the two

approaches sound suspiciously similar.



Some have suggested that components approaches are more efficient because

they use only the "active ingredient" components of protocols at key points

in the treatment and skip the unnecessary stuff. Unfortunately there is

precious little dismantling research discerning exactly what those active

ingredients are, and whether or not they only get active when the other

"unnecessary" components have been used as well (what one might call

conditional component efficacy). It may turn out that the components that

have been picked to be used actually do have the most impact even when not

used in concert with other techniques. Or not. This hypothesis remains to

be tested for most approaches.



Others have suggested that "components" approaches are more palpable to

clinicians because then they can use their clinical judgment when to do what

rather than following the strict rules of a protocol. However, as you point

out, many of the components approaches then proceed to teach elaborate rules

for when and how to use the particular components chosen and end up being

more complicated than protocols (but without the outcome research to support

their efficacy). While the whole components vs. protocols debate is an

interesting pastime for some of us, from an empirical testing standpoint, it

may be a debate without a difference. The empirical question still is,

"When therapists do this, do clients get better compared to when therapists

do that?" Call it what you will, components, protocols, or whatever, you

still have to define the "this" (aka independent variable) in sufficiently

replicable manner.



You second point about "focused" vs. "comprehensive" treatment planning also

is absolutely critical. At a recent training for about 50 CPS workers, I

gave them all a case we had seen recently in our clinic and asked them to

break into groups and come up with a treatment plan. the case was a typical

train wreck, multiproblem, abusive family. We then wrote on a flip chart

all of the interventions, treatments, programs and meetings they thought the

family should receive and go to. It took 4 large flip chart sheets to write

them all down. I then asked the workers two questions. First, did they

think any family in the world, much less this family, could get their child

to even half of the appointments they were recommending. Second, did anyone

in the room believe this was an effective treatment plan that would

accomplish the goals we had set for this family. No one in the room

believed any family (even their own) could accomplish half of the treatment

plan, and not one person thought it was an effective treatment plan. Yet

they wrote it. They agreed that they have been trained and acculturated to

simply add and add and add and add to treatment plans to the point of being

ridiculous. The good news is that at the end of the day, when challenged to

come up with a feasible treatment plan composed of evidence supported

interventions and programs, they were able to do it and the plan was about

1/3 of a flip chart page.



The notions that more is better and that doing an untested something is

always better than doing nothing permeates the system and needs to be

challenged.



Again, thanks for the elegant thoughts.



Ben



~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Benjamin E. Saunders, Ph.D.

National Crime Victims Research and Treatment Center

Medical University of South Carolina 843-792-2945 Phone

Charleston, SC 29425 843-792-7146 Fax



Visit our web sites: www.musc.edu/ncvc www.musc.edu/tfcbt

www.musc.edu/ctg www.musc.edu/saprevention

________________________________________

From: bounce-3422423-6832002@list.cornell.edu

[bounce-3422423-6832002@list.cornell.edu] On Behalf Of Chaffin, Mark J.

(HSC) [Mark-Chaffin@ouhsc.edu]

Sent: Wednesday, December 24, 2008 8:31 PM

To: Child Maltreatment Researchers

Subject: RE: Evidence-based and "Mix and Match" Programs



Tom,



Yaiiii....where to start. There is considerable interest in the idea of

extracting common elements from across evidence based models, then applying

these depending on assessed case characteristics and some systematic

algorithm. Probably the most detailed system of how this process might be

undertaken has been described by Chorpita and colleagues. Note, however,

that the processes for identifying both the elements themselves and the

matching algorithm as described by Chorpita are NOT just a matter of

logic-model 'mix and match' eyeballing based on the clinician's gut or

personal preferences. It is a quite structured and quantitative process.

It is still a protocol (and a complicated one at that), and not at all the

same thing as free-styling, fly-by-the-seat-of-the-pants services often

advocated by the anti-EBT crowd. If anything, it is a system probably

requiring more expertise and training than most simple EBT's. How well

these algorithm-driven, elements-based systems work in practice is a subject

of ongoing study. The jury is not in. Some EBT's such as MST, have done

essentially this same thing for years and its worked out well. MST, for

example, is not a single protocol, but is assessment driven and tailored,

yet focuses the intervention on what we know matters, using basic elements

that are known to work In this sense, there are fairly complex EBT's, such

as MST, which target broad populations, and more specific EBT's, such as

TF-CBT for example, which are specific for particular types of well-defined

problems (i.e. PTSD).



The elements-based idea does have a clear appeal--EBT's are probably not

monolithic entities incapable of being subdivided. Most share common

elements within a given domain (e.g. most evidence-based parenting programs

share many common elements such as use of labeled praise, application of

structured time-out protocols, etc.). However, I would be very skeptical of

efforts to use this rationale to neuter EBT's, or to simply say "oh, we're

already doing all that" or "this is the same thing" when it really isn't the

case. One need look no further than the Blueprints implementations to find

evidence of this, where well-intended shooting from the hip led to blending

in ad hoc crap with EBT's and spoiled the results. The point is that the

elements-based approach is not an excuse to allow anything and everything to

come into the intervention or to mix-and-match without some fairly tight

limits, such as those described by Chorpita and colleagues.



The area of most concern in your question lies in the idea of whether more

is better. There is excellent evidence at this point that this is not only

false but that more can become harmful. For example, where parenting

interventions are concerned, it appears that adding additional services to a

parenting program actually poisons the benefits (Kaminsky, et al.

meta-analysis). CPS and courts are notorious for this misconception--often

prescribing so many services that whatever benefits any of the services

might have offered may be quickly lost in the confusion. The analogy to

"polypharmacy" in psychiatry is not a bad one. Focus (i.e. directly

behaviorally targeting the top priority that needs to change) rather than

comprehensiveness (trying to fix everything), is the new watchword in many

service systems. Exactly how much is too much, and what demands the

highest priority is an unanswered empirical question. But the emerging

science in this area does, IMO, suggest a couple of general principles.

First, tailoring might work...IF the elements are selected carefully based

on scientific evidence and are clear essential common components across

EBT's. Second, there are clearly both practical and therapeutic limits to

how many things can be done well at once, and this point is reached rapidly

and past that point quickly begins to ruin the overall service benefit. So,

"focus" not "comprehensive" should be the watchword. We need to emphasize

this watchword because practitioners have been so imbued with the idea that

"comprehensive" is necessary that it takes considerable effort to disabuse

them of this unfortunate misconception. This is another reason why any

novel algorithm-driven, elements-based protocols need to be structured. And

why it needs to be rigorously evaluated. Keep in mind that implementations

of novel blended or elements-based programs cannot properly be called

evidence-based just because the sources for the elements were

evidence-based. For that matter, it cannot even be presumed to be effective,

altough we might predict that it would be.



Mark





________________________________________

From: Tom Hanna [tph3@cornell.edu]

Sent: Thursday, December 18, 2008 8:25 AM

Subject: Evidence-based and "Mix and Match" Programs



On another list, there is active discussion underway on starting an

"ancillary" parenting education program to an existing "core" home

visitation program. The conversation quickly turned to the topic of

"evidence-based", and then to funders and their requirements.



The picture quickly got cloudy for me:



1. Some folks who already have an ancillary parenting education

program reported that "blending" aspects of two evidence-based

programs allowed them to tailor the trainings to the specific needs

of their "home visited" parents. Others quickly pointed out that

this is "wrong" and should not be done -- neither evidence based

program is being followed precisely, and therefore both are

"contaminated." Funders frown.



2. No one has said what additive effect, if any, is expected from

providing a parenting program on top of a home visitation program.

The underlying assumption is that families will be better off with

two distinct interventions instead of one. (In fact, many centers in

this home visiting network have many ancillary programs that serve

some if not many of their home visited families.)



3. I know that lots of funders are demanding that agencies use

"evidence-based" programs. But I now learn that funders are pushing

implementation of a "matrix" of "evidence-based" programs. The

underlying assumption is that "if one evidence-based program is good

for families, then many are better."



My question: Is there any research that helps multi-service agencies

make their way through this minefield when working with a cohort of

families?

-- Any study of the "deterioration of effects" of the blending of two

evidence based models for the same intervention?

-- Any classical studies of "additive effects" of multiple targeted

interventions?

-- Any evidence that a "matrix" of evidence based programs has a

stronger effect than a "pure" one-program approach?

-- Any analysis that shows that evidence based programs in different

interventions (home visitation vs parenting ed vs therapy groups) are

(or are not) internally consistent? (ie, my doctor gave me one

instruction about diet, my nutritionist gave me a contradictory

instruction, and my home visitor's instruction differed from the

other two.)



TIA

Tom









--

--

Tom Hanna, Director

Child Abuse Prevention Network

www.child-abuse.com

tom@child-abuse.com

tph3@cornell.edu

off 607.275.9360

cel 607.227.4524

fax: 415.962.0510

--











Mark and Ben,



I am hesitant to get into the dialogue of two such titans in the field, but

am struck as I always am about the missing elements in our treatment

discussions. Both of you make incredibly important points and I too believe

deeply in science guiding our planning of treatment. But this discussion

leaves out two important elements in child protection work -- that I believe

we often we as researchers ignore -- WHO is actually doing the work and the

CONTEXT in which it is done. Coupled with the risk of a child death, both

may explain the desire to add and add and add.



Who - Most parent home visitors and caseworkers are not trained to do the

kind of work we want them to do. Indeed, I have seen home visitors who are

bank tellers or human resource workers or ones who did housing work. None

with prior training more than a workshop here and there. So we can develop

whatever intervention we like --we are still expecting someone to carry it

out. In many contract agency settings, supervision is minimal and

backgrounds of staff do not match the requirements of our protocols.



Where - In urban settings when I have visited homes to conduct research

interviews or in the past to do home interventions, I often have gone to

neighborhoods where a shooting has taken place just a week ago (setting off

a sense of vigilance even though I am seasoned in going to such

neighborhoods). I might have to step over a drunken neighbor who is passed

out on the stoop or the half drunk one, who insists on having a conversation

with me before I can get past them to get into the home. I then enter homes

where at times I am treated to a shouting argument between a man and a woman

that at moment feels like it will erupt into a physical fight. Other men

enter the home during the visit and stare rather belligerently at me or join

in taking the boyfriend's or husband's side. The woman may have no food and

the child appears sick. She is crying. This is the context where the work

is being done. Cognitive science tells us that cognition is disrupted under

such conditions.



Put a frightened young worker and this context together and add high risk

for a child and the worker is overwhelmed and wants all the help she can get

and probably is shaking too much to carry out anything in any standardized

way. It FEELS like more is better -- because the situation has so many

elements. She may habituate to this over time and with good supervision grow

into a decent practitioner who can carry out focused approaches. More likely

if she is good, she will leave the work for a job in a setting where she can

feel safe and carry out her work more effectively.



Yes -- in a the context of a workshop and under ideal conditions with the

right coach, caseworkers can come up with a good treatment plan that is

focused and may be enough to produce results -- but that is with a coach

like one of you and the safety of sitting in a room with nothing to lose and

no threats hanging over them.



Treatment development work in child maltreatment is unlike other treatment

development areas where most interventions are carried out by professionals

who have much education and in the context of an office setting. I want the

field to develop science based protocols, but until we deal with staffing

issues and focus our attention on methods for coping for staff -- the "add

and add and add" approach will continue to feel safer for most.



Sandra



------------

Sandra T. Azar, Ph.D.

Professor

Psychology Department, Moore 541

Pennsylvania State University

University Park, PA l6801

814-863-6019 (office)

sta10psu.edu



-----Original Message-----

From: bounce-3424753-6833833list.cornell.edu

[mailto:bounce-3424753-6833833list.cornell.edu] On Behalf Of Saunders PhD,

Benjamin E

Sent: Friday, December 26, 2008 11:44 PM

To: Child Maltreatment Researchers

Subject: RE: Evidence-based and "Mix and Match" Programs



Mark,

Thank you for the excellent summary of several very important issues. Two

points are particularly critical for future research. IMHO, the current

excitement in some quarters over "components" approaches to treatment vs.

manualized "protocols" is, from a research perspective, a red herring. As

you note, both must have some sort of decision rules about what to do next

at certain points in treatment. If not, they just become virtually random

in nature. So, the results of those decisions will need to be tested

empirically whether it means following a "protocol" or decision rules about

using components. Frankly, when one scratches the surface, the two

approaches sound suspiciously similar.



Some have suggested that components approaches are more efficient because

they use only the "active ingredient" components of protocols at key points

in the treatment and skip the unnecessary stuff. Unfortunately there is

precious little dismantling research discerning exactly what those active

ingredients are, and whether or not they only get active when the other

"unnecessary" components have been used as well (what one might call

conditional component efficacy). It may turn out that the components that

have been picked to be used actually do have the most impact even when not

used in concert with other techniques. Or not. This hypothesis remains to

be tested for most approaches.



Others have suggested that "components" approaches are more palpable to

clinicians because then they can use their clinical judgment when to do what

rather than following the strict rules of a protocol. However, as you point

out, many of the components approaches then proceed to teach elaborate rules

for when and how to use the particular components chosen and end up being

more complicated than protocols (but without the outcome research to support

their efficacy). While the whole components vs. protocols debate is an

interesting pastime for some of us, from an empirical testing standpoint, it

may be a debate without a difference. The empirical question still is,

"When therapists do this, do clients get better compared to when therapists

do that?" Call it what you will, components, protocols, or whatever, you

still have to define the "this" (aka independent variable) in sufficiently

replicable manner.



You second point about "focused" vs. "comprehensive" treatment planning also

is absolutely critical. At a recent training for about 50 CPS workers, I

gave them all a case we had seen recently in our clinic and asked them to

break into groups and come up with a treatment plan. the case was a typical

train wreck, multiproblem, abusive family. We then wrote on a flip chart

all of the interventions, treatments, programs and meetings they thought the

family should receive and go to. It took 4 large flip chart sheets to write

them all down. I then asked the workers two questions. First, did they

think any family in the world, much less this family, could get their child

to even half of the appointments they were recommending. Second, did anyone

in the room believe this was an effective treatment plan that would

accomplish the goals we had set for this family. No one in the room

believed any family (even their own) could accomplish half of the treatment

plan, and not one person thought it was an effective treatment plan. Yet

they wrote it. They agreed that they have been trained and acculturated to

simply add and add and add and add to treatment plans to the point of being

ridiculous. The good news is that at the end of the day, when challenged to

come up with a feasible treatment plan composed of evidence supported

interventions and programs, they were able to do it and the plan was about

1/3 of a flip chart page.



The notions that more is better and that doing an untested something is

always better than doing nothing permeates the system and needs to be

challenged.



Again, thanks for the elegant thoughts.



Ben



~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Benjamin E. Saunders, Ph.D.

National Crime Victims Research and Treatment Center

Medical University of South Carolina 843-792-2945 Phone

Charleston, SC 29425 843-792-7146 Fax



Visit our web sites: www.musc.edu/ncvc www.musc.edu/tfcbt

www.musc.edu/ctg www.musc.edu/saprevention

________________________________________

From: bounce-3422423-6832002list.cornell.edu

[bounce-3422423-6832002list.cornell.edu] On Behalf Of Chaffin, Mark J.

(HSC) [Mark-Chaffinouhsc.edu]

Sent: Wednesday, December 24, 2008 8:31 PM

To: Child Maltreatment Researchers

Subject: RE: Evidence-based and "Mix and Match" Programs



Tom,



Yaiiii....where to start. There is considerable interest in the idea of

extracting common elements from across evidence based models, then applying

these depending on assessed case characteristics and some systematic

algorithm. Probably the most detailed system of how this process might be

undertaken has been described by Chorpita and colleagues. Note, however,

that the processes for identifying both the elements themselves and the

matching algorithm as described by Chorpita are NOT just a matter of

logic-model 'mix and match' eyeballing based on the clinician's gut or

personal preferences. It is a quite structured and quantitative process.

It is still a protocol (and a complicated one at that), and not at all the

same thing as free-styling, fly-by-the-seat-of-the-pants services often

advocated by the anti-EBT crowd. If anything, it is a system probably

requiring more expertise and training than most simple EBT's. How well

these algorithm-driven, elements-based systems work in practice is a subject

of ongoing study. The jury is not in. Some EBT's such as MST, have done

essentially this same thing for years and its worked out well. MST, for

example, is not a single protocol, but is assessment driven and tailored,

yet focuses the intervention on what we know matters, using basic elements

that are known to work In this sense, there are fairly complex EBT's, such

as MST, which target broad populations, and more specific EBT's, such as

TF-CBT for example, which are specific for particular types of well-defined

problems (i.e. PTSD).



The elements-based idea does have a clear appeal--EBT's are probably not

monolithic entities incapable of being subdivided. Most share common

elements within a given domain (e.g. most evidence-based parenting programs

share many common elements such as use of labeled praise, application of

structured time-out protocols, etc.). However, I would be very skeptical of

efforts to use this rationale to neuter EBT's, or to simply say "oh, we're

already doing all that" or "this is the same thing" when it really isn't the

case. One need look no further than the Blueprints implementations to find

evidence of this, where well-intended shooting from the hip led to blending

in ad hoc crap with EBT's and spoiled the results. The point is that the

elements-based approach is not an excuse to allow anything and everything to

come into the intervention or to mix-and-match without some fairly tight

limits, such as those described by Chorpita and colleagues.



The area of most concern in your question lies in the idea of whether more

is better. There is excellent evidence at this point that this is not only

false but that more can become harmful. For example, where parenting

interventions are concerned, it appears that adding additional services to a

parenting program actually poisons the benefits (Kaminsky, et al.

meta-analysis). CPS and courts are notorious for this misconception--often

prescribing so many services that whatever benefits any of the services

might have offered may be quickly lost in the confusion. The analogy to

"polypharmacy" in psychiatry is not a bad one. Focus (i.e. directly

behaviorally targeting the top priority that needs to change) rather than

comprehensiveness (trying to fix everything), is the new watchword in many

service systems. Exactly how much is too much, and what demands the

highest priority is an unanswered empirical question. But the emerging

science in this area does, IMO, suggest a couple of general principles.

First, tailoring might work...IF the elements are selected carefully based

on scientific evidence and are clear essential common components across

EBT's. Second, there are clearly both practical and therapeutic limits to

how many things can be done well at once, and this point is reached rapidly

and past that point quickly begins to ruin the overall service benefit. So,

"focus" not "comprehensive" should be the watchword. We need to emphasize

this watchword because practitioners have been so imbued with the idea that

"comprehensive" is necessary that it takes considerable effort to disabuse

them of this unfortunate misconception. This is another reason why any

novel algorithm-driven, elements-based protocols need to be structured. And

why it needs to be rigorously evaluated. Keep in mind that implementations

of novel blended or elements-based programs cannot properly be called

evidence-based just because the sources for the elements were

evidence-based. For that matter, it cannot even be presumed to be effective,

altough we might predict that it would be.



Mark





________________________________________

From: Tom Hanna [tph3cornell.edu]

Sent: Thursday, December 18, 2008 8:25 AM

Subject: Evidence-based and "Mix and Match" Programs



On another list, there is active discussion underway on starting an

"ancillary" parenting education program to an existing "core" home

visitation program. The conversation quickly turned to the topic of

"evidence-based", and then to funders and their requirements.



The picture quickly got cloudy for me:



1. Some folks who already have an ancillary parenting education

program reported that "blending" aspects of two evidence-based

programs allowed them to tailor the trainings to the specific needs

of their "home visited" parents. Others quickly pointed out that

this is "wrong" and should not be done -- neither evidence based

program is being followed precisely, and therefore both are

"contaminated." Funders frown.



2. No one has said what additive effect, if any, is expected from

providing a parenting program on top of a home visitation program.

The underlying assumption is that families will be better off with

two distinct interventions instead of one. (In fact, many centers in

this home visiting network have many ancillary programs that serve

some if not many of their home visited families.)



3. I know that lots of funders are demanding that agencies use

"evidence-based" programs. But I now learn that funders are pushing

implementation of a "matrix" of "evidence-based" programs. The

underlying assumption is that "if one evidence-based program is good

for families, then many are better."



My question: Is there any research that helps multi-service agencies

make their way through this minefield when working with a cohort of

families?

-- Any study of the "deterioration of effects" of the blending of two

evidence based models for the same intervention?

-- Any classical studies of "additive effects" of multiple targeted

interventions?

-- Any evidence that a "matrix" of evidence based programs has a

stronger effect than a "pure" one-program approach?

-- Any analysis that shows that evidence based programs in different

interventions (home visitation vs parenting ed vs therapy groups) are

(or are not) internally consistent? (ie, my doctor gave me one

instruction about diet, my nutritionist gave me a contradictory

instruction, and my home visitor's instruction differed from the

other two.)



TIA

Tom









--

--

Tom Hanna, Director

Child Abuse Prevention Network

www.child-abuse.com

tomchild-abuse.com

tph3cornell.edu

off 607.275.9360

cel 607.227.4524

fax: 415.962.0510

--